A coroner has demanded to know how an 88-year-old grandmother was allowed to starve to death in a care home.

Irene Willits, who worked as a bus conductress during the Second World War, was reduced to an ‘emaciated skeleton’ after care home staff failed to check she was eating properly.

When she finally died of severe malnutrition, she weighed just 4st 12lb – the weight of a seven-year-old child.

Coroner Simon Nelson said he was so horrified to hear what happened to Mrs Willits, that he is to write to the local health authorities and even the police to raise his concerns.

Irene Wilits (pictured in 2003 with her great grandaughter Sophie Lovel) weighed less than five stone at the time of her death and was described as looking like a 'skeleton with skin pulled over' despite being in a care home and categorised as 'high risk'

The inquest heard that doctors who saw Mrs Wilits at hospital before she died 'couldn’t believe that she had come from a care home'.

Now her daughter Yvonne Newell has hit out at her care at Ashbourne Nursing Home in Rochdale, Greater Manchester, saying 'We were let down. No one should die of malnutrition in modern-day Britain.'

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The inquest heard that the former Second World War bus conductor and grandmother had 'slipped through the net', after staff at the nursing home failed to carry out appropriate record keeping for almost a month in the lead up to her death in September 2009 and a review by her dietitian had failed to take place.

Irene Wilits as a bus conductor during WWII

One doctor at the hospital said that medical help should have been sought sooner, whilst the pathologist said she had 'looked like a skeleton' with a BMI of just 13.

Pathologist Dr Samer Al Habba said: 'She looked like a skeleton so I’m not surprised about her low weight, she was extremely malnourished.

'She should have had medical intervention, there wasn’t enough care.

'She was well underweight. It is impossible to gauge the time scale that dehydration had occurred.'

Mrs Willits had been a resident at the home since November 2008 after a series of mini strokes and problems arising surrounding weight loss caused her to be hospitalised.

When she was discharged, she
was initially expected to stay in the care home for one month but
ended up remaining because she had shown improvements in her health and
eating and put on just under a stone (6 kg).

The
inquest heard that she was categorised as 'high risk' and needed her
weight to be continually monitored, but over the next six months her
weight dropped.

Her
daughter, Yvonne Newell, 66, giving evidence, said that she had visited
her elderly mother regularly and four days before her death in September
2009, had noted that she was becoming more frail.

She
also raised concerns that the care home was not keeping records
up-to-date which was brought to the attention of the coroner, Simon
Nelson.

An investigation by Greater Manchester Police after her death found that Ashbourne House had 'fulfilled all their requirements'.

DC
Desmond Henry had told the hearing that he 'didn’t feel there were any
grave concerns about the medical staff or medical providers' and that 'all documentation completed was of higher than average standard.'

But
coroner Mr Nelson hit out at the care home’s record keeping and GMP
after it was found that there were no care records from August 10, 2009
- bar a report on August 16, 2009, that referred to a slight weight
gain.

Irene Wilits' daughter Yvonne Newell (pictured) said that she is still looking for answers as to why her mother died: 'I still want to know how this happened, I think that when the coroner said she fell through the net he was right. I still have reservations about what happened in the days leading up to her death'

Mrs Newell said: 'She went in a lot better health than what she was in the end. I assume if somebody needs care then they are given it.

'I can’t believe that a care home
would leave someone in such a state without water and not admit her to
hospital. It is inconceivable that that would happen and also not to
advise me how bad she was.'

Irene on her Wedding Day in 1947

Dr
Shauna Macullen said that when the grandmother arrived at Rochdale
Infirmary she was dehydrated and 'didn’t have any more weight to lose'.

'She
was chronically underweight. The deceased didn’t have any more weight
to lose. The nursing staff (at the hospital) were concerned with the
poor physical state she was in.'

Mrs Willits’s health failed to improve and she died the following day.

Dr
Macullen added that she had been 'surprised' the hospital staff hadn’t
seen Mrs Willits before, adding: 'She was very very unwell, but
deterioration can be very rapid. She can’t have drank for a couple of
days. I do believe they should have sought medical help sooner.'

Area care home manager for Ashbourne
Nursing Home, Francesca Stewart said: 'Any concerns a home has about
weight or diet are referred to the outside professionals.

'The home did pass on the concerns to the outside services.

'It
was evident that Irene was seen regularly by external professionals and
at no time prior to her death did the external professionals raise
concerns about the care provided by the home and was not considered to
be at risk.

'The staff
at the home regularly encouraged her to eat and take in more fluids,
this is confirmed from her notes. Whilst the home would raise any
necessary concerns to her well being, it was ultimately for the visiting
nurses, GP, district nurses and community dietician to administer.'

She said that she accepted that
records should have contained entries on a weekly basis and accepted
that it was good practice to chase up any outside assessments.

Community
staff nurse with Pennine Acute Trust, Lynn O’Connor had implemented a
care plan for Mrs Willits because she was at risk of malnutrition.

She
said that she had expected that the staff at the care home would carry
out weekly weigh ins, record the weight and liaise with the dietician
adding that this was 'very important'.

Mrs Wilits (centre, with her daughter Yvonne, left) had been a resident at the home since November 2008 after a series of mini strokes and problems arising surrounding weight loss had caused her to be admitted to hospital

Returning a narrative verdict Mr Nelson said: 'In March 2009 her weight was 38.4 kilos, in May 35kg, August 33kg and at post mortem 31kg. These figures demonstrate a loss of over 10 per cent over a period of six months.

'It was imperative that her weight was maintained.

'Overall there were no concerns over the care of Mrs Willits prior to August 10 but the relevant records thereafter simply do not exist.

'The cause of death by the doctor was malnutrition which is an extremely rare cause of death.

'Record keeping is a major concern both within the acute setting and case homes. If it is not there it hasn’t taken place, it is as simple as that. There is no explanation of the absence of appropriate record keeping.

'I also have concerns about the vulnerable adult section compiled by the Greater Manchester Police about the completion of the care home records. It is supposed to evaluate the quality of the records provided by the care establishment.

Mrs Newell (pictured with her husband outside Heywood Coroners Court) said: 'There was no way this happened overnight. I couldn't believe how she looked when I saw her that morning at the home, she was totally emaciated'

'It was suggested that there was nothing untoward. Having seen the actual records I do not share that evaluation and I will be writing to GMP to express my concerns.

'I am also extremely concerned and have had communication with Pennine Acute Trust that she didn’t have another dietary review.

'She died of malnutrition which more than likely was caused by a combination of naturally occurring disease.'

Speaking after the inquest Mrs Newell, a retired export administrator, said that she was still looking for answers as to why her mother died.

The coroner said that he had concerns about record keeping at Ashbourne Nursing Home in Rochdale, where Mrs Wilits starved

She said: 'I still want to know how this happened, I think that when the coroner said she fell through the net he was right. I still have reservations about what happened in the days leading up to her death.

'I know what she looked like when she went into hospital. If you imagine a skeleton with skin pulled over it, that was what she looked like. It was horrible.

'There was no way this happened overnight. I couldn’t believe how she looked when I saw her that morning at the home, she was totally emaciated. I would have liked to have known what she weighed at that stage before they pumped her full of fluid but they couldn’t weigh her. I have never seen anything like it.

'You don’t expect someone in this country to die of malnutrition it’s a third world problem, yet it happened.'

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WWII bus conductor was like an 'emaciated skeleton' weighing just less than five stone after she was left to starve in a care home